Caffeine Withdrawal

Caffeine Withdrawal has a well-characterized constellation of symptoms (Table 2), and it is classified as a Caffeine-Related Disorder Not Otherwise Specified in the Diagnostic and Statistical Manual of the American Psychiatric Association (APA).67

Table 2. Symptoms of Caffeine Withdrawal

Headache

Sleepiness/drowsiness

Impaired concentration/lassitude/work difficulty

Depression

Anxiety

Irritability

Nausea/vomiting

Muscle aches/stiffness

The IHS recommends a diagnosis of caffeine-withdrawal headache when patients experience bilateral and/or pulsating head pain:

Within 24 hours of interrupting or delaying caffeine intake

After consuming more than 200 mg of caffeine per day for at least 2 weeks

That is relieved within 1 hour by 100 mg of caffeine and resolved within 7 days of abstinence from caffeine.50

In most patients, pain of moderate to severe intensity generally begins within 18 hours after caffeine intake ceases; it peaks about 3-6 hours after onset.68 Attacks typically begin with a feeling of cerebral fullness or pressure and develop into a diffuse, throbbing pain.68 The symptoms of caffeine-withdrawal headache are exacerbated by physical activity. One-quarter of patients experiencing withdrawal will report mild nausea and feelings of depression or sadness.68,69

To facilitate diagnosis, providers should use the patient history to query regular caffeine intake from all sources, including diet and medication (Rx and OTC). While patients who chronically consume 500-600 mg caffeine per day are more likely to suffer from caffeine-withdrawal headache, especially if their caffeine intake has suddenly stopped or been interrupted, research has shown that Caffeine Withdrawal symptoms are not dose-related.50 Some patients show minimal withdrawal from high doses of caffeine, while others may show signs of withdrawal from lower doses. What constitutes excessive intake, therefore, is highly individualized. Providers should also be alert for symptomatic overlap, as the withdrawal syndrome can resemble migraine and clinical depression.68

It is possible that the frequency and distribution of Caffeine Withdrawal symptoms have been overstated in the medical literature because subjects knew they were participating in research about the effects of Caffeine Withdrawal, and prior knowledge may have biased their responses. A study by researchers at Harvard Medical School and at the University of Pennsylvania explored this possibility by using a survey instrument that did not directly reference caffeine consumption or attitudes about caffeine, investigators interviewed more than 11,000 subjects.70 Most (61%) respondents said they consumed caffeine daily, but only about 11% reported experiencing withdrawal symptoms due to an interruption or delay of their regular intake, and only 3% (0.9% of men and 5.5% of women) considered their withdrawal symptoms debilitating. In a second phase of the study, 57 subjects who reported that they had experienced withdrawal symptoms were included in a randomized, double-blind study comparing abrupt and staged caffeine cessation. Only one-third (33.3%) of abruptly stopped subjects had withdrawal symptoms, and none of the subjects who underwent staged reduction had withdrawal symptoms. The researchers concluded that the frequency and severity of caffeine-withdrawal symptoms may be less common in the general population than previously believed, and that more people report a history of caffeine-withdrawal symptoms than experience them under double-blind conditions.70

Evidence suggests that caffeine-withdrawal headache can be minimized by a staged reduction and elimination of caffeine intake. Although there is no published or anecdotal evidence linking the use of caffeinated analgesics to symptoms of Caffeine Withdrawal, all forms of caffeine (including caffeine-containing medications) should also be temporarily eliminated. To ease the transition, providers should attempt to enlist the support of family members. Educating patients will help them understand the withdrawal process and the importance of moderating intake of caffeine in the future.